Provider Demographics
NPI:1346681426
Name:CHANGING LIVES FAMILY CARE HOME LLC
Entity Type:Organization
Organization Name:CHANGING LIVES FAMILY CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:QUENTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-516-7296
Mailing Address - Street 1:823 DAY AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2505
Mailing Address - Country:US
Mailing Address - Phone:336-516-7296
Mailing Address - Fax:
Practice Address - Street 1:823 DAY AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2505
Practice Address - Country:US
Practice Address - Phone:336-516-7296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health